A horse named ‘Twilight Sleep’: the language of obstetric anaesthesia in 20th century Britain

International Journal of Obstetric Anesthesia (2005) 14, 310–315 Ó 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2004.12.011

HISTORICAL COMMENTARY

A horse named ‘Twilight Sleep’: the language of obstetric anaesthesia in 20th century Britain Richard Barnett Wellcome Trust Centre for the History of Medicine at University College London, UK SUMMARY. Historians of medicine frequently marginalize or completely ignore the importance of linguistics in the development and dissemination of medical theories and clinical techniques, both in professional culture and in society at large. This is particularly true in the history of pain relief in labour, despite the significant role played by popular attitudes to birth and pain relief in the development of clinical services. This paper uses a simple form of citation analysis to examine shifts in the usage of terms related to regional nerve block techniques in The Lancet and The Times from 1900 to 1999. Graphical representations of these data are used to relate changes in the incidence of citations to key events in the 20th century history of obstetric anaesthesia in Britain. A study of the rise and fall of Ôtwilight sleep’ in the early part of the century is used to demonstrate the advantages and disadvantages associated with this approach to medical history. Conclusions from this analysis are used to suggest (tentative) models for the acceptance and diffusion of medical words in professional and popular vocabularies. Ó 2005 Elsevier Ltd. All rights reserved. Keywords: History of medicine; History of obstetric anaesthesia; History of language

ness. One might expect this process to be particularly acute in the field of obstetric anaesthesia, given the high proportion of the population who have received pain relief in labour and the widespread public interest in issues around childbirth. But how may this process be assessed? Perhaps the simplest approach would be to look for the origins of particular terms (both in dictionaries and in the historical record) and then, taking the British situation as an example, following their progress through the British popular and medical press. This approach will not revolutionise our understanding of the technical and clinical history of pain relief in labour. It may, however, cast light on an under-rated but crucial relationship: that between medical practice and its public understanding.

“Twilightsleep idea: queen Victoria was given that”. Stephen Dedalus in James Joyce, Ulysses (1922).

She wasn’t, of course. Any history of pain relief in labour1 will reveal the facts: that in 1853 Dr. John Snow gave Victoria Ôthe blessed chloroform’ for the birth of Leopold, her eighth child. But in his drunken reverie Stephen Dedalus makes, inadvertently, a fundamental point about the nature of medical words. The protean complexity of language seems to suggest that, in reaching for precise definition, scientific and medical words access a higher world of truth and permanence. This is not, however, the case. Words and their meanings are hijacked, reinterpreted, recycled, discarded, and popular culture plays a central role in this process. Once defined, accepted and in use, a medical term has a frustratingly democratic tendency to be taken up, with a completely different sense or meaning, in the collective conscious-

ORIGINS A search of the latest edition of the Oxford English Dictionary (OED), now available online,2 gives us the following first citations:  The first reference to spinal anaesthesia appears in what is acknowledged3 as the first description of the procedure: J Leonard Corning’s paper4 in the New York Medical Journal in 1885.

Accepted December 2004 Sources of support: This research is supported by a joint Wellcome Trust/Obstetric Anaesthetists’ Association PhD studentship. Correspondence to: Richard Barnett, Wellcome Trust Centre for the History of Medicine at University College London, 210 Euston Road, London NW1 2BE, UK. E-mail: [email protected] 310

Language of obstetric anaesthesia in 20th-century UK 311  Nerve block, in the sense of a deliberately induced obstruction of nerve impulses for the purposes of anaesthesia, seems to have been coined in an editorial in the Journal of Laryngology, Rhinology & Otology in 1912.  Saddle block as a variation of spinal analgesia appears in what is, again, accepted to be the first account of the technique: Ray Parmley and John Adriani’s 1946 paper5 in the American Journal of Obstetrics and Gynecology.  Block, as an umbrella term for regional nerve block techniques, is first cited as late as 1957, in the Encyclopaedia Britannica’s entry on ÔAnaesthesia’.  The Guardian appears, rather surprisingly, to have been in the vanguard of anaesthetic neology: the OED claims that the first use of epidural analgesia is on the paper’s front page on 12th September 1968, and of the abbreviated form epidural on page nine of the paper for 7th April 1970.  Regional anaesthesia, regional analgesia, caudal analgesia, peridural, extradural and caudal (in an anaesthetic rather than anatomical sense) are not cited in the OED. What does this reveal? At first glance, little. The OED’s examples of first citations relating to spinal anaesthesia and analgesia fit with what is known6 of the technique’s early history: Corning’s observation in 1885, the first surgical application by August Bier in Kiel in 18997 and the first use in obstetrics by Oskar Kreis in Geneva in 1900.8 Similarly, the first citation of Ôsaddle block’ is roughly consistent with the first clinical report of the technique. ÔEpidural,’ on the other hand, seems completely out of step with the accepted chronology. Indeed, the OED appears to have its facts wrong: Ôepidural analgesia’ appears in The Lancet at least as far back as the 1950s.9 This inconsistency, however, demonstrates one of the strengths of this type of study. The OED records usage – a word or phrase’s entry to (and exit from) both popular and professional vocabularies. The influence of the Woolley and Roe case on British spinal anaesthesia in general and obstetric anaesthesia in particular has been widely documented.10 In 1947 Albert Woolley and Cecil Roe, two patients on the same operating list at the Chesterfield and North Derbyshire Royal Hospital, suffered paraplegia and other problems after they both received light spinal anaesthesia. A third patient on the same list died a few days after surgery. In 1953 Woolley and Roe sued the Ministry of Health, the trustees of the hospital and the anaesthetist, Dr J Malcolm Graham, for damages, but lost the case.11 It seems that the OED citation reflects the gradual rise in popularity of epidural analgesia as the impact of Woolley and Roe made anaesthetists unwilling to use spinal anaesthesia. Since that time, Ôepidural’ has en-

tered the popular lexicon in a way that none of the other words discussed here have: hence the familiar image of the parturient who shouts ÔGive me an epidural!’ In this instance the OED citation appears to reflect usage, both of the word and of the technique, rather than origin. Perusing the pages of a dictionary (even one so august as the OED) can reveal only so much. Throughout the 20th century both The Times and The Lancet have remained widely read and highly esteemed publications in Britain, one in the popular sphere and the other in the medical sphere. Both have complete back runs available in digitised form,12 hence both may be searched for the incidence of particular terms over a given period. It is frequently assumed (for example in citation index analyses) that if a paper is widely cited it is either influential or controversial.13 Does this assumption apply to individual words? If so, what variation in usage may be observed between the popular and medical press?

Regional and obstetric anaesthesia in The Lancet and The Times Before examining any citation data, it is worth considering what Ôshape’ of histogram the known history of regional nerve block techniques might suggest. For The Times an initially high rate of citations around 19001910 might be predicted, as the techniques were announced and publicised. Little or no press interest might then be expected until the 1940s, when the work by Robert Hingson14 and Edward Tuohy15 on caudal analgesia began to attract attention. A peak associated with ÔWoolley and Roe’ in the early 1950s seem inevitable, followed by a lull as the techniques fell out of use, and finally a gradual rise in citation rates from around 1970 as they gradually came back into use and popular interest in the Ôepidural’ grew. What might we expect in The Lancet? The basic shape could be similar, with perhaps a higher overall rate of citation reflecting the journal’s specialised medical remit. Perhaps also, since the majority of The Lancet is devoted to research rather than news stories, there might be an additional peak in the interwar years (when much of the groundwork research in regional anaesthesia was published) (Fig. 1). Fig. 1 compares the incidence of citations relating to regional anaesthesia in The Times and The Lancet for successive five-year periods from 1900 to 1999. Considering The Times first, how well do these data relate to the hypothetical distribution? Badly, at least in the early period. Until 1930 the only citations are two reports from the 1913 Congress of Medicine in London.16 From 1930 citations begin to appear more regularly, but there is no identifiable ÔHingson peak’. After 1950, however, the fit of the model improved. All 10 citations from 1950-54 relate to ÔWoolley and Roe’. Interestingly, all

312 International Journal of Obstetric Anesthesia 180

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19 00 19 04 05 19 -09 10 19 14 15 19 -19 20 19 24 25 19 29 30 19 -34 35 19 39 40 19 -44 45 19 49 50 19 -54 55 19 59 60 19 -64 65 19 69 70 19 74 75 19 -79 80 19 84 85 19 -89 90 19 94 95 -9 9

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Fig. 1 Citations relating to regional pain relief in The Times and The Lancet, 1900-1999. Search terms: Ôepidural,’ Ôepidurals,’ Ôepidural analgesia,’ Ôspinal anaesthesia,’ Ôspinal anaesthetic’ and Ôspinal analgesia’.

nine citations for 1960-64 also relate to a legal case, that of Dr Wladyslaw Alexander Dering.17 Dering sued Leon Uris, an American author, who alleged that Dering had performed several thousand sterilisations without anaesthesia while working as a surgeon in the camp hospital at Auschwitz. Dering won by showing that he had used spinal anaesthesia, but was awarded damages of a halfpenny. The post-Woolley and Roe decline is clearly visible, but contrary to the hypothesis it appears to have lasted until the late 1970s. Eight out of 25 citations for 1980-84 relate to the case of Carol Brown.18 In January 1979 Mrs Brown suffered paralysis and persistent pain after being given epidural analgesia during labour at St George’s Hospital, Tooting. In 1981 she sued the Merton Health Authority, and was awarded record damages of £414 563. One further citation in this period relates to the death of a woman in childbirth in 1984 after a badly placed epidural, but no other similar incidents or deaths were noted.19 Moving to the data from The Lancet: there is indeed a much higher overall citation rate, but the shapes of the two distributions are clearly different. The early peak around 1910 is present, and the slump that follows it should perhaps be seen in the context of the generalised decline in medical publishing during World War I. In 1917 The Lancet published a total of 1987 articles, compared with 3245 in 1913 and 2350 in 1919. However, the most obvious feature of the graph is the high peak in 1930-34, and the sustained decline that follows it. The citations that comprise the peak are not related to a particular event: two thirds of them are clinical research papers with no obvious common theme apart from regional nerve block techniques, and the remainder are divided

(along approximately equal lines) between news articles, book reviews and letters. One factor in this sustained decline is the rise to prominence of British anaesthetic periodicals such as the British Journal of Anaesthesia (founded in 1923) and Anaesthesia (founded in 1946). Their growing stature meant that the (generalist) Lancet was no longer seen as the best place to publish new research in anaesthetics. From 1930-34 until 1980-84 there were no identifiable peaks: the drop reached its nadir in 1965-69 (arguably the height of post-Woolley and Roe concern over spinal anaesthesia), but the recovery after this is limited. The 1980-84 peak contained no citations relating to the Brown case, and in the final two decades of the century The Lancet’s citation rate actually dropped below that of The Times (Fig. 2). A comparison of the incidence of the terms Ôepidural’ (widely used in colloquial parlance) and Ôspinal anaesthesia’ (less so) may be revealing. Fig. 2 compares the incidence of citations relating to spinal anaesthesia and epidural analgesia/anaesthesia in The Lancet for successive five-year periods from 1900 to 1999. The first and most obvious point about these data is their close resemblance to Fig. 1: similar peaks and troughs, and approximately comparable citation rates. Taking this resemblance further, the data for citations relating to spinal anaesthesia in Fig. 2 appear closely related to those for The Lancet in Fig. 1, and the data for citations relating to epidural analgesia in Fig. 2 are, although less congruent, at least comparable to those for The Times in Fig. 1. Superficially, at least, this supports the idea that the propagation and use of medical terms should be described in terms of professional/ popular interaction.

Language of obstetric anaesthesia in 20th-century UK 313 180 160

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Citations relating to epidural analgesia Citations relating to spinal anaesthesia and analgesia

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19 00 -0 19 4 05 -0 19 9 10 -1 19 4 15 -1 19 9 20 -2 19 4 25 -2 19 9 30 -3 19 4 35 -3 19 9 40 -4 19 4 45 -4 19 9 50 -5 19 4 55 -5 19 9 60 -6 19 4 65 -6 19 9 70 -7 19 4 75 -7 19 9 80 -8 19 4 85 -8 19 9 90 -9 19 4 95 -9 9

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Fig. 2 Epidural’ and Ôspinal’ in The Lancet, 1900-1999. Search terms: Ôepidural,’ Ôepidurals,’ Ôepidural analgesia,’ Ôcaudal analgesia,’ Ôcaudal anaesthesia,’ Ôspinal analgesia,’ Ôspinal anaesthesia’ and Ôspinal anaesthetic’.

Twilight sleep Up to this point this paper has been concerned with the history of techniques that still form the bedrock of modern obstetric anaesthesia: spinal anaesthesia, epidural analgesia and so on. Twilight sleep (the use of hyoscine with various opioids) to induce maternal amnesia during parturition) appears, on the other hand, to be widely regarded as an embarrassing anomaly in the history of pain relief in labour, and for this reason it is marginalized or ignored completely by many historians on the subject.20 However, twilight sleep was for a time both popular with the public and controversial amongst medical professionals.21 For this reason, a citation analysis is a most suitable way of exploring its rise and fall. References to twilight sleep in the OED are consonant with its known early history. In 1902 Richard von Steinbuchel, a professor at the University of Graz, began to inject mothers with morphine and scopolamine during birth.22 His technique was elaborated by Carl Gauss in Freiburg, who in 1906 coined the term Dammerschlaf (literally, Ôdusk sleep’).23 The OED cites Gauss’s paper as the first use of Dammerschlaf, and Frederick Hewitt’s Anaesthetics and Administration (1912) as the first use of twilight sleep (Fig. 3). The technique was most popular in the US, but also found some favour in Britain. Fig. 3 compares the incidence of references to twilight sleep and Dammerschlaf in The Times and The Lancet for successive five-year periods from 19001999. These data are again entirely consistent with the accepted view of twilight sleep as a historical phenomenon: a brief, intense burst of interest and controversy,

followed by an equally rapid decline into obscurity. In this case (as opposed to that of regional pain relief illustrated in Fig. 1) the majority of interest appears to have been popular rather than medical. This point is emphasised by the observation that almost all references in The Times are advertisements (49 advertisements out of a total of 53 citations in 1915-19; 163 out of 173 in 1920-24; 360 out of 360 in 1925-29; 7 out of 25 in 1930-34). The following is a fairly typical example of such an advertisement from 1925: “ST FAITH’S NURSING HOME, EALING, W.5. Est. 32 years. All cases. Separate house for MATERNITY, TWILIGHT SLEEP or other. Resident Physician. Own doctor can attend. Quiet. Good garden. Moderate fees. Tel. Ealing 1485. Ealing Broadway four minutes”.24

This high proportion of advertisements from practitioners offering twilight sleep suggests that demand for the technique came from patients rather than medical professionals, and this is supported by the lower rate of citation in The Lancet. It is interesting to note that, although in The Lancet the terms Dammerschlaf and twilight sleep appear with roughly equal frequency, Dammerschlaf is never used in The Times. It may be the case that the anti-German attitude in British popular culture during and after World War I militated against the use of a German name for a technique so closely associated with childbirth. It is also possible to discern from these data a shift in the usage of the term twilight sleep. After 1935 the word appears in The Times only in non-medical, metaphorical contexts. All six citations for 1935-39 relate to a

314 International Journal of Obstetric Anesthesia 400

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Fig. 3 Twilight sleep’ and Dammerschlaf in The Times and The Lancet, 1900-1999. Search terms: Ôtwilight sleep’ and ÔDammerschlaf’.

racehorse named Twilight Sleep.25 This is a startling example of linguistic drift: the phrase has moved from an obscure German paper on obstetric pain relief in 1900 to enter British popular culture in the late 1930s. From 1940 the phrase appears to have developed a new meaning: a culpable state of stupor in times of crisis. It is used in this sense in an article criticising the Coal Board in 1944,26 and also in a letter by Malcolm Muggeridge in 1968.27 It also appeared as a crossword clue in 1967.28 A similar shift may be discerned in The Lancet: after 1950 the term appears only in obituaries and reminiscences.29

DISCUSSION What conclusions can we draw from this limited historical survey? Taking first the example of regional nerve block techniques, I suggest that what has been observed here may be one model for the acceptance and dissemination of medical terms within the professional and public consciousness. In the early part of the period a majority of references to the techniques are found in professional publications: the idea is vague, still under development, and so the term is poorly understood and rarely used. Only when the technique is more widely accepted in the professional world does the word begin to enter the public vocabulary, at first through high-profile events such as criminal trials and litigation, and then through a more general process in which the technique’s place in medical practice is negotiated by both the profession and the public. In the case of twilight sleep, how-

ever, this model must be extended to include the exit of a term from the medical vocabulary as the technique falls out of use, and the renegotiation of its usage and meaning in the popular consciousness – the horse named Twilight Sleep. An extension of this survey to include 1850 to 1900, the inclusion of a wider range of periodicals and the extension of the survey into an international context, or a breakdown of The Lancet and Times citations by authorship or article type, would provide an opportunity to flesh out this description (in particular the details of the process of negotiation) and to work out more fully its implications for the history of anaesthesia. In writing the history of medicine, words are often neglected in favour of more concrete subjects for study: techniques, equipment, individuals or organisations. This insular approach ignores the central role of language in definition, communication, education and dissemination of knowledge. It is also one-sided: medical words may be created by medical practitioners, but their usage and acceptance is determined by the interaction not only of clinicians but also of patients, journalists, legislators and many other groups. Words are not simply vectors, carrying information from one mind to another. They can themselves transform our thoughts, our understanding and our practices.

ACKNOWLEDGEMENTS The author wishes to thank Dr. Tilli Tansey and Dr. Anita Holdcroft for their comments on an early draft of this paper.

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